Just hearing the word Botox brings up an image of a wrinkle free brow, the absence of crow’s feet and the loss of vertical lines between the eyebrows. Most people don’t realize, however, that Botox was not developed to be a plastic surgeon’s wonder drug. Some of the approved indications for Botox include the treatment of:
2-blepharospasm (involuntary blinking or spasm of the eyelids),
3-cervical dystonia (spasm of the neck muscles with the head twisted to one side),
4-hyperhidrosis (excessive sweating) and
5- a cosmetic indication (the temporary improvement of vertical glabellar rhytids (wrinkles).
My friend and colleague Dr. Alexander Mauskop uses Botox to treat patients suffering from severe, chronic migraines. (https://nyheadache.com/ ). Many of the current cosmetic indications for the use of Botox are off-label. although, that has not limited its application. According to the statistics of the two major American plastic surgery societies the American Society of Plastic Surgeons (www.plasticsurgery.org ) and The Aesthetic Society (www.surgery.org ) , Botox is the most performed cosmetic procedure by plastic surgeons. (https://www.plasticsurgery.org/news/plastic-surgery-statistics and https://www.surgery.org/sites/default/files/ASAPS-Stats2018_0.pdf )
Backed by their experience and comfort with Botox, it is not surprising that surgeons are discovering new and diverse ways to use Botox to treat a variety of non-cosmetic conditions. There have recently been several experimental and clinical studies investigating the use of Botox for the treatment of scars. Hypertrophic and keloid scars remain one of the most troublesome problems after surgery and trauma. The public, as well as many physicians and surgeons, use the terms hypertrophic and keloid scarring interchangeably. In fact, they are different. The differentiation between a hypertrophic and a keloid scar is a clinical one. A hypertrophic scar is raised, red and thick, but is confined to the site of the surgical incision or injury. They often respond to medical treatment. A keloid scar on the other hand extends outside the site of the original injury, can become quite large, and are often resistant to treatment.
Some of the modalities plastic surgeons use to improve such scars include surgery, pressure, microneedling and, probably most frequently, steroid injections. As a plastic surgery resident, we would go one afternoon a week to “Keloid Clinic” where we would inject hypertrophic and keloid scars with steroids (usually triamcinolone) to reduce them and improve their appearance. Chen, H-C, et. al. ( Plast. Reconstr. Surg. 140: 43e, 2017 ) studied the effect of Botox on hypertrophic scars in an experimental model. Their study groups included the use of triamcinolone alone, Botox alone and triamcinolone and Botox combined. There was a statistically significant reduction in hypertrophic scars in those scars treated with both Botox and Triamcinolone as compared to the other groups. Fanous, A, et. al (Plast. Reconstr. Surg. 143: 760, 2019) looked at the effect of Botox on keloids and found a beneficial action as well.
In a clinical study, Kim, YS, et. al. (Wound Repair Regen. 2014;22:605–612) found that in a group of patients undergoing thyroid surgery, there was a statistically significant improvement in the scarring at 6 months with the use of Botox. Laarakker and Borah (Plast. Reconstr. Surg. 145: 161, 2020.) looked at the use of Botox in a group of patients who suffered severe hand injuries which jeopardized the blood flow to their hands. The results were impressive as Botox seemed to not only preserve the involved hands and fingers, but also seemed to decrease pain levels and bring the patients back to function earlier.
Although there is more work to be done and more evidence required before Botox will be accepted as an established treatment option for hypertrophic and keloid scars, the data is encouraging.